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Medical coding Sample coded Report – 1 US BREAST BIOPSY RIGHT HISTORY: Suspicious 11 mm solid palpable lesion 5:00 6 cm from the nipple. PROCEDURE: Risks and procedure were discussed with the patient in Spanish and written informed consent was obtained. The right breast was prepped and draped in the usual manner. Buffered 1% lidocaine was … Read more
Question 1 Which CPT code would be reported for a cystourethroscopy with removal of a ureteral calculus? 52320 52325 52332 52352 Question 2 A physician performs a cystourethroscopy with ureteroscopy and treatment of intra-renal stricture through balloon dilation. Which CPT code would be reported? 52344 52345 52346 52351 Question 3 Which CPT code would be … Read more
Medical coding Sample Chart 1 PREOPERATIVE DIAGNOSIS: Left shoulder instability with labral tear. POSTOPERATIVE DIAGNOSIS: Left shoulder instability with labral tear. PROCEDURE: Left shoulder arthroscopic stabilization. SURGEON: INDICATIONS FOR SURGERY: The patient is a 28-year-old who has had multiple dislocations of the left shoulder.He has been able to self reduce for the most part.However, he … Read more
Sample coded Medical coding report 1 DIAGNOSES: 1. Chronic adenotonsillitis 2. Upper airway resistance. PROCEDURES: 1. Tonsilloadenoidectomy. INDICATION FOR PROCEDURE: The patient presents with a history of chronic adenotonsillitis, which had been appropriately treated by Dr. . The patient has persistent hypertrophy of her tonsils with copious amount of cryptic concretions with 3+ tonsillar enlargement. … Read more
Sample Medical Report 1 PREOPERATIVE DIAGNOSIS: Right laryngeal lesion. POSTOPERATIVE DIAGNOSIS: Right laryngeal lesion. PROCEDURE: Microsuspension laryngoscopy with excision of right laryngeal lesion. ANESTHESIA: General. ESTIMATED BLOOD LOSS: Minimal. SPECIMENS REMOVED: Right laryngeal lesions. COMPLICATIONS: None. INDICATIONS FOR SURGERY: The patient is an 84-year-old man with a history of dysphonia. He was found by … Read more
Sample coded Surgery chart 1 History: The patient is a 39-year-old male with a history of end-stage renal disease. The patient has an indwelling left upper extremity brachiocephalic hemodialysis fistula with reports of increased venous pressures and suboptimal dialysis. Comorbidities: 1. Hypertension. 2. End-stage renal disease Services performed: 1. Diagnostic fistulagram Date of service: Following explanation of … Read more
PREOPERATIVE DIAGNOSIS: Atypical skin lesions. POSTOPERATIVE DIAGNOSIS: Atypical skin lesions ANESTHESIA: Local 1% lidocaine, 0.5% Marcaine and bicarbonate. FINDINGS: 1. It is a 1 cm right upper arm lesion, a). A 3 cm x 1 cm excision. 2. 1.2 cm left supraclavicular lesion a). A 4 cm x 1.5 cm excision. 3. Multiple skin tag … Read more
Medical coding Sample Chart 1 Procedure: Port-A-Cath removal Preoperative diagnosis: no longer needs port a cath Postoperative diagnosis: same. Indications: The patient is a 62 year old woman who no longer needs a port a cath due to completion of treatment. . I had a conversation with the patinet about the risks and benefits of … Read more
Sample coded Medical coding chart 1 Indication for Surgery Partial tear left Achilles with retrocalcaneal bursitis Preoperative Diagnosis As above Postoperative Diagnosis As above Operation 1. Left Achilles tendon debridement/repair 2. Excision of Haglund’s deformity and retrocalcaneal bursa 3. Intraoperative radiographs with immediate interpretation by surgeon Surgeon(s) Anesthesia General anesthesia Estimated Blood Loss Minimal Findings … Read more
Medical Coding Sample Report 1 PREOPERATIVE DIAGNOSIS: Left perineal lipoma. POSTOPERATIVE DIAGNOSIS: Left perineal lipoma. PROCEDURE: Excision of 5 x 7 left perineal lipoma. SURGEON: INDICATIONS FOR SURGERY: This is a 70-year-old female who had a left perineal lipoma excised 10 years ago in Iran.Since then, it has been growing and is very uncomfortable.It bulges out of … Read more